Legislature(1997 - 1998)
03/09/1998 09:06 AM HES
* first hearing in first committee of referral
= bill was previously heard/scheduled
= bill was previously heard/scheduled
SENATE HEALTH, EDUCATION AND SOCIAL SERVICES COMMITTEE March 9, 1998 9:06 a.m. MEMBERS PRESENT Senator Gary Wilken, Chairman Senator Loren Leman, Vice-Chairman Senator Lyda Green Senator Jerry Ward Senator Johnny Ellis MEMBERS ABSENT None COMMITTEE CALENDAR SENATE BILL NO. 331 "An Act regulating licensed professional counselors; regulating use of the titles 'licensed professional counselor' and 'licensed counselor'; amending Rule 504(a)(3), Alaska Rules of Evidence; and providing for an effective date." HEARD AND HELD SENATE BILL NO. 321 "An Act relating to assisted living homes." MOVED CSSB 321(HES) OUT OF COMMITTEE PREVIOUS SENATE COMMITTEE ACTION SB 331 - No previous Senate committee action. SB 321 - No previous Senate committee action. WITNESS REGISTER Beth Hagevig Staff to Senator Wilken Alaska State Capitol Juneau, Alaska 99801-1182 POSITION STATEMENT: Testified for the sponsor of SB 331 Ann Henry 3347 Park Place Juneau, Alaska 99801 POSITION STATEMENT: Supports SB 331 Pamela Watts American Counseling Association of Alaska P.O. Box 240554 Douglas, Alaska 99824 POSITION STATEMENT: Supports SB 331 Robert Pound Southcentral Counseling Center 3725 Spinnaker Drive Anchorage, Alaska POSITION STATEMENT: Supports SB 331 Allan Morotti Alaska School Counselors' Assn. 791 Goldstreak Road Fairbanks, Alaska 99712 POSITION STATEMENT: Dixie Hood 222 Seward St., Suite 210 Juneau, Alaska 99801 POSITION STATEMENT: Supports SB 331 SENATOR MIKE MILLER Alaska State Capitol Juneau, Alaska 99081-1182 POSITION STATEMENT: Sponsor of SB 321 John Pierce 430 4th Street Fairbanks, Alaska 99701 POSITION STATEMENT: Supports SB 321 Dwight Becker Division of Senior Services Department of Administration 3601 C Street, Room 310 Anchorage, Alaska 99503 POSITION STATEMENT: Supports SB 321 Rose Heyano Bristol Bay Native Association P.O. Box 310 Dillingham, Alaska 99576 POSITION STATEMENT: Supports SB 321 Cathy Westling 329 D Street Fairbanks, Alaska 99701 POSITION STATEMENT: Supports SB 321 Monta Lane 109 E 5th Street North Pole, Alaska 99705 POSITION STATEMENT: Supports SB 321 Debbie Cask 3291 Jefferson Drive Fairbanks, Alaska 99709 POSITION STATEMENT: Supports SB 321 Helen Powell 1913 Jack Street Fairbanks, Alaska 99709 POSITION STATEMENT: Supports SB 321 Sharon Kenamon 2106 Flight Street North Pole, Alaska 99705 POSITION STATEMENT: Supports SB 321 Judith Townsend 120 Pepperdine Drive Fairbanks, Alaska 99709 POSITION STATEMENT: Supports SB 321 Derrill Johnson Department of Health & Social Services P.O. Box 110620 Juneau, Alaska 99811-0620 POSITION STATEMENT: Commented on SB 321 Sharon Clark Legislative Aide to Senator Mike Miller Alaska State Capitol Juneau, Alaska 99801-1182 POSITION STATEMENT: Commented on SB 321 ACTION NARRATIVE TAPE 98-22, SIDE A Number 001 CHAIRMAN WILKEN called the Senate Health, Education and Social Services (HESS) Committee to order at 9:06 a.m. Present were Senators Wilken, Leman, Ward, and Green. CHAIRMAN WILKEN announced the committee was waiting for a committee substitute for SB 321 to arrive, therefore SB 331 would be heard first. SB 331 - PROFESSIONAL COUNSELOR LICENSING CHAIRMAN WILKEN informed committee members a new draft version of SB 331 was prepared (version B). SENATOR WARD moved to adopt CSSB 331 (version B) as the working document of the committee. There being no objection, the motion carried. BETH HAGEVIG, legislative aide to Senator Wilken, gave the following explanation of the measure. CSSB 331 establishes a board to license and regulate experienced Masters and Doctoral level professional counselors whose education and experience do not fall within the existing behavioral health specializations of Licensed Clinical Social Worker, Licensed Marriage and Family Therapist, Psychologist, or Psychological Associate. This bill benefits counselors because it opens doors to employee assistance programs that currently require that service providers be licensed to qualify for their programs; it broadens career opportunities for counselors who wish to work for entities that require licensure; it provides incentive for Masters level behavioral health graduates of Alaska's university system to stay in state and take advantage of licensing opportunities that already exist in 44 other states; and it includes licensed professional counselors under Rule 504, protecting them from contempt of court, in cases where client confidentiality must be protected. MS. HAGEVIG explained CSSB 331 is good for Alaska's consumers because it establishes a minimum standard of education and experience that clients can trust, eliminating the buyer beware situation that currently exists. It institutes grievance procedures and gives legal recourse for clients of licensed professional counselors who feel they have been victims of fraudulent, unethical, or negligent practices. It gives clients, who require mental health services, greater choice and comfort in choosing a provider that best suits their needs, both emotionally and financially, and it increases the availability of licensed mental health providers who practice statewide, giving rural residents better access to mental health care. This bill has the support of the American Counseling Association (ACA), the ACA of Alaska, the Alaska School Counselor Association, numerous professional counselors and clients. Number 082 CHAIRMAN WILKEN pointed out a two-page document in committee members' packets shows where Alaska fits into the scheme of counselor licensing nationwide. The remainder of the packet contains letters of support. SENATOR LEMAN noted SB 122, dealing with family and marriage counselors, is currently in the House. He asked Ms. Hagevig if any thought was given to combining the counseling and marriage and family therapy boards into a common board, instead of creating a new board. He commented he serves on a professional board made up of architects, engineers and land surveyors, and although the professions differ, their common board is able to take care of the professional interests of all three groups. MS. HAGEVIG replied the counselors support combining the boards and are working with the marriage and family therapists' board members on creating a joint board. She suggested asking Pamela Watts and Ann Henry, from the American Counseling Association of Alaska, to address that question. Number 122 ANN HENRY, a member of the American Counseling Association of Alaska (ACAA), gave the following testimony. SB 331 is a title restriction bill, rather than a practice restriction bill, which means that people can continue to practice counseling in Alaska if they are practicing now. That arrangement will especially benefit the bush areas where counselors might now be practicing without the required education. Nationally, 44 states have some kind of licensure certification and 80,000 licensed professional counselors are nationally recognized. As a private practitioner, clients are often referred to her, but because she is not a licensed practitioner, employee assistance programs will not provide insurance coverage for her services. Managed care programs also require licensure. Ms. Henry believes clients need to be able to choose their counselor. MS. HENRY noted that in regard to Senator Leman's question about combining the two boards, the marriage and family therapists' board supports SB 331 and discussed, at its last meeting, the need to speak to ACAA about the possibility of combining the boards. The ACAA definitely favors combining the boards. She assumed that counselors will not be a viable group for the family and marriage therapists' board to deal with until they get licensing certification in Alaska. Number 172 PAM WATTS, President of the American Counseling Association of Alaska, gave the following testimony. When ACAA began efforts to require counselor licensure, it heard from several University of Alaska graduates who were having difficulty obtaining and maintaining employment or advancing in their positions. They support licensure because the lack of licensure requirements is limiting employment opportunities for them after they graduate. A second issue is that hundreds of Masters and Doctoral level counselors are currently providing counseling services around the state. ACAA is concerned that without licensure, they will not be able to practice, and in some cases, they are the only people available in those areas to do this work. Because they are trained to provide a range of counseling services that are not necessarily limited to the specialty licenses that Alaska currently has, such as marriage and family, or psychology or social work, they do not fit anywhere in the licensure scheme. SB 331 offers consumer protection, easier access to mental health services, and will provide Alaskans the opportunity to pursue occupations within the state for which they have been trained. MS. WATTS reiterated that ACAA is interested in looking at combining with the marriage and family therapists' board. She agreed that closely related fields can function very well on combined boards. She pointed out that other states, such as Georgia, have an omnibus board that includes social workers, chemical dependency counselors, licensed professional counselors and marriage and family therapists. She thought creating a similar board in Alaska in the future would be fiscally responsible. Number 227 SENATOR LEMAN encouraged Ms. Watts to further the dialogue about combining the two boards because he thought SB 331 would be a good vehicle in which to do so this year. He advised that if they do not combine boards, counselors will incur all of the initial costs of establishing a separate board which will increase the fees. CHAIRMAN WILKEN asked about the status of SB 122. SENATOR LEMAN stated it is in the House and he believes it is scheduled to pass. ROBERT POUND, a counselor with Southcentral Counseling Center in Anchorage, testified in support of SB 331. The Southcentral Counseling Center has developed a system in which a person must be licensed to reach the highest level of clinician. SB 331 would enable him to obtain a license and become a senior clinician. Without a licensing requirement in Alaska, agencies are forced to find people outside of the state to fill these positions. Requiring experience and education will ensure better quality treatment to clients. He received a professional counselor license in the State of Colorado around 1989. That license allowed him to do contract work, EAP work, and to have a private practice. The certification process requires a disclosure statement to be filled out by clients. He found clients responded very positively and the ability to do so relieved clients of worry. Mr. Pound believed SB 331 will have positive results on both counselors and consumers. Number 308 ALLAN MOROTTI, representing the Alaska School Counselors' Association, and the counseling program at the University of Alaska Fairbanks, gave the following testimony. The Alaska School Counselors' Association supports SB 331. Many rural counselors feel that passage of SB 331 will improve the delivery of mental health services. Students from the UAF program who end up counseling in rural areas often find themselves functioning in the role of a crisis counselor. As they move from site to site, the majority of their work is dealing with crisis issues, rather than the more traditional school counseling issues. Passage of SB 331 will allow those counselors to get the additional supervision necessary to provide quality mental health services, and passage will allow many of UAF's graduates to move out into the mental health agencies. Once employed by those agencies, the graduates feel pressured to acquire some type of licensure. Many agencies hire out-of-state because of the lack of licensed practitioners in the state. He believes the course work for Masters level counselors nationwide, in the area of supervision, clinical hours, diagnosis and appraisal, compares favorably with the requirements for clinical social workers and marriage and family therapists. He concluded by saying he strongly supports the bill both as an individual and on behalf of the Alaska School Counselors' Association. Number 371 CHAIRMAN WILKEN asked Mr. Morotti his opinion of combining the counselors' board with the marriage and family therapists' board. MR. MOROTTI said he thinks it is a good idea because he sees no need to have a proliferation of boards providing mental health services. DIXIE HOOD, a licensed marriage and family therapist from Juneau, and a member of the Board of Marital and Family Therapy, gave the following testimony. As a 23 year Alaska resident and psychology professor at the University of Alaska Southeast, she moved to California to complete a Masters in Counseling program for two years. That program required 3,000 supervised hours and an oral and written exam. She was licensed in California and upon returning to Juneau in 1985, contacted the Division of Occupational Licensing to find out what requirements she needed to meet to practice. Purchase of a business license was the only requirement until 1992. She commented that marriage and family therapy is not a specialty field. It is a theoretical approach in terms of counseling individuals, couples, or family members within the family systems approach and their interrelationships. Marriage and family therapists also treat people with alcohol problems, serious chronic mental illness, and depression and anxiety. MS. HOOD indicated at the February 10, 1998 Marital and Family Therapy Board meeting, the Board expressed interest in supporting standards and licensure for professional counselors in Alaska, and in discussing with them consideration of a combined board. The board has sought information from other states with omnibus boards to find out how their systems work. MS. HOOD commented she has testified on and followed SB 122; it is scheduled before the House Labor and Commerce Committee this afternoon for a second hearing. During the first hearing, held last week, information was requested and an amendment was discussed. The same amendment failed the Senate last year and would have added licensed marriage and family therapists to a list of health care providers who cannot be discriminated against in third party reimbursements. MS. HOOD believes it is important for consumers to have some trust in the amount of training and experience required of mental health providers. Licensure requirements are also important for the professional in terms of standing in the professional community and employee assistance programs and insurance companies. SENATOR LEMAN noted his memory of what happened regarding the amendment differed from Ms. Hood's. He recalled the amendment passed the Senate but its passage created challenges in the bill that some did not want to address at the time, therefore the amendment was removed and the bill passed. MS. HOOD added the amendment created a furor from chiropractors, dentists and other professionals. The Omnibus Insurance Reform Act did not take up that amendment, therefore the Board of Marital and Family Therapy is hoping it will be taken up in SB 122 or in another venue. There being no further testimony on SB 331, CHAIRMAN WILKEN announced the committee would hold the bill to investigate whether it can be incorporated into SB 122 or vice versa. SENATOR LEMAN stated whether SB 122 is the right vehicle in which to combine the boards or not, he thought the Legislature should consider combining the two boards and use a separate piece of legislation if necessary. CHAIRMAN WILKEN indicated the bill would be brought before the committee on Wednesday and a report on SB 122 would be provided. SB 321 - ASSISTED LIVING FACILITIES CHAIRMAN WILKEN announced a committee substitute had been prepared for SB 321. SENATOR WARD moved to adopt CSSB 321 (version F) as the working document of the committee. There being no objection, the motion carried. SENATOR MIKE MILLER, District Q, discussed the reason he introduced SB 321. His father was placed in an assisted living care facility in North Pole as a private pay client. Through the course of his father's stay, the family saw the type of loving care given to his father until he passed away and to the other clients. One other client was a private pay; the other clients were paid for by the state for which the caregiver received $34.50 per day. Senator Miller cautioned that if the current amount paid to assisted living caregivers is not increased, more and more caregivers will quit providing services because the care provided in these homes is very demanding upon the caregivers. If fewer caregivers are available, families will have to send elderly relatives to places like Denali Center, which costs the state a couple of hundred dollars per day. Assisted living facilities are a less expensive alternative, and they provide a different type of environment which some people prefer. SENATOR MILLER maintained he was not sure how the increased cost associated with SB 321 will be paid, but he felt dialogue on long term care issues must begin. He concluded by saying he cannot speak highly enough about the caregivers who provide this service and the type of care his father received and he believes increasing the amount of funds they receive is the right thing to do. CHAIRMAN WILKEN questioned how the $70 amount was calculated. SENATOR MILLER replied his staff worked with a number of assisted living caregivers to come up with that number. Since the last increase in 1983, many expenses have increased, such as insurance rates. CHAIRMAN WILKEN asked if assisted living homes require licensure and if they take more than one client at a time. SENATOR MILLER answered this particular home was licensed by the State of Alaska to house up to five individuals at a time. He added that private pay clients go to the top of the waiting list because they pay more. His father's care cost $100 per day, but had he been in an institution, the cost would have been much higher. He noted a number of the individuals who live in assisted living facilities do so until they pass on. CHAIRMAN WILKEN pointed out that Mr. Kohn of the Pioneer Home estimated there will be 30,000 s and enter an educational institutional setting eniors in the State of Alaska in the year 2000 or 2005 while only be 600 Pioneer Home beds will be available. Number 552 JOHN PIERCE, Vice President of Senior Quality Care Incorporated, which owns and operates an eight-bed facility named "Summer Shade," made the following remarks. One cannot even find a good motel room in Fairbanks for $34.50, yet assisted living facilities offer 24 hours per day of care for that amount. In his facility everyone is licensed as at least a CNA. His clients need various levels of care; some need borderline nursing home services; some are taken in emergency situations. The paperwork submitted for clients who qualify for state monies normally takes 60 to 90 days to process. He asked that the amount of payment be dependent upon the level of care needed. Mr. Pierce thought assisted living facilities are competing unfairly with Pioneers Homes because Pioneers Homes do not accept clients for $34.50 per day. After he does the paperwork for some of his clients, and their health improves, they are often transferred to a Pioneer Home. TAPE 98-22, SIDE B Number 580 DWIGHT BECKER, Program Coordinator with the Division of Senior Services, stated he supervises programs of adult protection and assisted living facility licensing, and he administers the general relief program statewide. He maintained assisted living providers are a very important part of the senior services network. They do not only provide services for seniors, they also provide services to anyone 18 years of age and over who is a vulnerable adult with a mental or physical impairment. He believes providers are long overdue for some type of increase. The clientele they are now serving are becoming more difficult to provide for. More clients have mental health problems, alcohol and substance abuse related problems, and are violent. Many clients have multiple health care needs requiring a whole array of services. In Alaska the assisted living providers market rate for taking care of such clients runs about $2500 to $3000 per month. The general relief program pays a base rate of $30 in Anchorage; a cost of living differential is applied to other areas around the state. He supports some type of increase. Everyday, his agency receives calls from hospital discharge planners, police departments, and others looking for facilities in which to place people who are at risk of becoming homeless and/or are at risk of abuse, neglect, or self-neglect. Alaska has almost 100 assisted living homes statewide, and rarely do they refuse to take a client, even at the low rates. Number 550 ROSE HEYANO, the social services director for the Bristol Bay Native Association (BBNA), informed committee members that BBNA is currently assisting in the development of a ten bed facility to be located in Dillingham. Funding for that facility is contained in the senior citizen housing development fund in the Governor's capital budget request. BBNA is relying on medicaid choice funds and the daily base rate paid by DHSS for adults in residential care for this operation. This funding is not adequate to make the facility self sufficient. BBNA needs at least $1400 per month per client to be self-supporting. The goal of the region is to develop a ten-bed facility in Dillingham and then smaller facilities in Togiak and New Stuyahok. BBNA found that in 1996, 16 elders left the region, yet everyone of them could have been placed in assisted facilities if the space was available. Local residents want to keep their elderly relatives close by. BBNA estimates that nine out of 10 beds will be filled by low-income people on fixed incomes. The operational costs in rural Alaska are much higher than in urban areas. BBNA determined from a survey it conducted last year there are 80 elders in the region. It currently has a home care program that has placed over 50 personal care attendants in over 70 elders' homes in the region. An assisted living facility will provide one more level of care for elders who need to make that transition. It will be less expensive in the long run to keep elders closer to home. MS. HEYANO encouraged committee members to help BBNA in its endeavor to develop more assisted living facilities in its region. CATHY WESTLING, representing Downtown Care Assisted Living, and the secretary of the Alaska Caregivers' Association, stated that assisted living is a model of care in the State of Alaska. Essentially, foster care turned into assisted living two to three years ago. Caregivers are a self-governing body of independent business owners who are required to be licensed, monitored and accountable. The goal of assisted living is to deinstitutionalize care as long as possible; assisted living caregivers need recognition and support. These business owners are required to pay insurance and workers' compensation, yet the base rate has not changed since 1983. Downtown Care Assisted Living is a ten-bed facility that employs seven employees: often native employees, employees off of welfare roles, and employees who are related to clients. It has housed many displaced elders who come from rural areas to Anchorage for medical care. Ms. Westling indicated that many of her clients have alcohol and substance abuse problems, and/or have been abused and exploited. These clients need help learning how to deal with relationships. She gets involved in restraining orders, guardianship issues, probate court, and getting people into counseling. Clients in assisted living facilities need care 24 hours per day. With a higher base rate for clients, she would like to hire more escorts to get clients active in the community. She added the State of Washington pays $55 per day as its base rate. MS. WESTLING indicated she has many clients with mental health and developmental disability problems. These clients can be very disruptive and sometimes it takes up to one year to receive funding for those clients. She believes the homeless population with mental illness or developmental disabilities will suffer the most if the rates are not raised. MONTA LANE, owner of a five-bed facility in North Pole, and President of Alaska Caregivers' Association, thanked Senator Miller for his efforts and made the following statements. She started her business in 1991, which was known as adult foster care at that time. The rate of pay in 1991 for general relief clients was $30.91; the amount increased by $2.60 in 1992. Nursing homes are not designed to take care of people who have reached a point to where they need to be in an assisted living type of setting. As clients get older, they usually deteriorate and often die in the assisted living facility. Clients become part of a family, and it is difficult to lose them. Regarding the question about the increase to $70 per day, Ms. Lane said she originally requested $100 per day with a sliding fee for people who require more care. She has detoxed clients. The Legislature appropriated $21 million for alcohol and substance abuse problems, yet none of that money is available to assisted living homes or the adult protection agency. Almost every assisted living home in the Interior has alcohol related dementia seniors in their homes. Ms. Lane emphasized assisted living facility owners work 24 hours per day yet they get no overtime pay nor do they have insurance, retirement funds or vacations. She noted she had a client for seven years who recently passed away. After making several attempts to find his family over the years, she located his children in Portland, Oregon, who thought he had passed away. This client did pass away two weeks later after speaking to his family for the first time in 12 years. She repeated her request for a base rate of $100 per day with a sliding fee scale for clients with chronic alcohol or mental illness problems. Number 374 DEBBIE CASK, owner of Debbie's Fireside Homes, stated she is having a difficult time keeping employees because she cannot compete with the wages offered by nursing homes. She noted assisted living facilities owners are receiving $1.44 per hour per client which is barely enough to buy food. To keep employees, she needs to offer health insurance and competitive wages. She recently hired three people from the welfare roll but had to let them go because she could not afford to keep them. She said many clients need to be hand fed, changed daily, and turned every few hours, among other things. CHAIRMAN WILKEN clarified that language on lines 9-12 allows the department, by regulation, to provide for a daily rate higher than $70 if the additional care justifies the additional reimbursements. SELMA ROBINSON, owner of Robinson Care, stated at present she has a limited number of clients, and is concerned that the $34.50 is not sufficient to take care of a person in her home. She has part- time help but can afford no more. HELEN POWELL, owner of a five-bed assisted living home, stated it is very difficult for her to keep her business open if she is not full all of the time. She serves three meals and snacks each day, hires employees, pays higher utility bills, and provides an array of services for her elderly clients. Number 313 MS. B JARVI, a professional guardian, stated the minimum wage is over $5 per hour, yet caregivers only receive $1.44 per hour which is an injustice. Often she must plead with caregivers on short notice to take clients because they are in intolerable living situations. The assisted living facility caregivers find room for these clients every time and sometimes without knowing if they will get paid at all. Pioneers Homes and similar facilities will not take people on short notice and are often full. Ms. Jarvi said she could not even put a client in a hotel room for $34.50 per night, let alone hire someone to watch the client. She noted when clients who are in the Denali Center for recuperative purposes are able to leave, she moves them to an assisted living facility as quickly as possible because the clients do better in a home environment. They are treated with dignity and are included in family life. She stated her support for a substantial raise to caregivers. SHARON KENAMON, an assisted living facility owner, stated she has been in business for 1+ years and is barely paying her bills. She is unable to provide any transportation to clients other than for medical visits and cannot afford to provide any activities. Two clients she housed were recently released and she never received payment for them. Caregivers need an increase in the pay rate in order to be able to provide activities for their clients. JUDITH TOWNSEND, owner of Center of Care, stated she opened her facility one year ago after working as an RN in a hospital for six years. She believes many people have a bad feeling about nursing homes, and many elderly want to stay in their own homes, so assisted care facilities are the next best thing because clients live in a family atmosphere. Clients often need assistance with daily care, but they do not have the money to pay for such care. The base rate of $34.50 does not cover the cost of providing for these clients. Direct costs alone can run $170 per day. She believes a base rate of $100 per day would be much more appropriate to ensure clients receive adequate care from trained caregivers. CHAIRMAN WILKEN thanked all participants for testifying today and stated that although the money is an important issue, caregivers are motivated by more. He thanked them for their services to a needy group of people. DERRILL JOHNSON, Division of Mental Health and Developmental Disabilities in the Department of Health and Social Services, stated assisted living facilities are probably one of the most important new industries in the state and are necessary as part of the state's long term care plan. DHSS recognizes that the compensation system needs to be revised, whether that be the fee structure or in the compensation methodology which determines the true cost of care. DHSS would like to see the fee structure based on an individual's needs rather than a fixed rate. DHSS also believes a public hearing process should be held before determining the rate because Alaska has a variety of vendors with different needs. MR. JOHNSON stated the assisted living home industry is relatively new and is a combination of the adult foster care program and the adult residential care program. DHSS has been aware of problems that have occurred with the combination of those two programs and of the low rate, but it has not had the resources to adjust the fees to a $70 minimum. CHAIRMAN WILKEN asked if a sliding fee scale based on need is used, whether a method to grade the needs will have to be created at an additional expense to the state. MR. JOHNSON replied that individualized funding is used with developmentally disabled clients. The cost of care is negotiated based on a care coordinator's plan and with an independent third party who works with the family of the consumer. The necessary services are costed out with a vendor. Mr. Johnson thought using a tiered fee schedule which allows flexibility to individualize each plan would work best. In some of the outlying areas where assisted living facilities need further development, staff and expertise may not be available to determine individually negotiated costs. If a tiered system with parameters was available to use as a baseline to explain what costs are associated with what needs, caregivers could more easily determine realistic costs. Mr. Johnson said the need for quality care is the driving force behind assisted living facilities therefore comparable wages need to be paid for that care. CHAIRMAN WILKEN gave the gavel to Senator Leman and excused himself to attend another hearing. SENATOR WARD referred to Section 7 of the committee substitute and said he understood that section to mean that $70 is established as the base rate but that rate could be increased if a client requires extra care. Senator Ward commented he was pleased to see this legislation because this is what he came to Juneau to do, not to spend $120 per day to house prisoners. SHARON CLARK, legislative aide to Senator Mike Miller, sponsor of SB 321, informed committee members the two lists in committee members' packets were provided by DHSS, and DHSS staff has been very helpful in drafting this bill. She pointed out there are 138 assisted living homes throughout the state. The Alaska Caregivers' Association resolution contains a breakdown of the amount provided on a daily basis to each caregiver, compared to what each one should receive. Committee packets also contain a resolution from the Alaska Commission on Aging. MS. CLARK commented this summer she spent a lot of time speaking with people in rural areas about this approach. They were excited about creating assisted living homes in their areas so their elderly do not have to leave. She noted many elderly are sent to Denali Center or other facilities in urban areas and can no longer see family members because the cost of travel is prohibitive. ALISON ELGEE, Deputy Commissioner of the Department of Administration, which administers the senior services programs, gave the following testimony. The base rate being discussed is the rate for general relief funds. Once an individual qualifies for a medicaid waiver, which requires the individual to need a nursing home level of care, the department has the ability to negotiate the amount of compensation paid to the assisted living home facility. She cautioned there will always be individuals in a general relief category who do not meet the nursing home level of care but are incapable of living independently. Many come through adult protective services and need emergency placement. The department has discovered that people who move into an assisted living environment before their needs get to a nursing home level of care can generally be maintained in a less expensive environment for much longer. The department's primary concern with SB 321 is the fiscal note because the cost of paying the base rate of $70 per day for existing clientele alone will be substantial. VICE CHAIR LEMAN stated he shares Ms. Elgee's concern about how to address the costs, but he also shares Senator Ward's concerns. TAPE 98-23, SIDE A MONTA LANE repeated that caregivers need to receive a minimum of $70 per day for general relief clients in their homes, and more for clients who need special services. She informed committee members it sometimes takes five months to get clients on a medicaid choice waiver. During that time the caregiver must provide for the client out of pocket and is then retroactively reimbursed only to the date the plan of care was signed which may have occurred two months after the client arrived at the home. She added that non-profit organizations can get grants to build assisted living care facilities but private owners get no assistance to maintain their homes. SENATOR WARD commented he worked on similar legislation in 1982 and that he will have no trouble finding enough money to fund SB 321. He moved to pass CSSB 321 out of committee with individual recommendations and its accompanying fiscal note. There being no objection, the motion carried. SENATOR WARD informed committee members he has not yet received the final legislative bill on child support enforcement provisions from the Idaho Legislature. VICE-CHAIR LEMAN announced the next HESS meeting is scheduled on Wednesday at 9:00 a.m. He adjourned the meeting at 10:45 a.m.